HomeMy WebLinkAbout0030 IRONSIDE DRIVE - Health 3D IRONSIDE DR, W. BARNSTABLE
A =
TOWN OF BARNSTABLE
LOCATION 3® 1ro,0.5;Ge_ Lance SEWAGE# 201 1 v 5 6
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. C61t nw i cL 674 k er�3e5 L_Lc_
SEPTIC TANK CAPACITY 1000
LEACHING FACILITY:(type) o e,s f/his (size) 0 `42,S
NO.OF BEDROOMS
OWNER 'Pe.+t;f, y `o 5 o J
PERMIT DATE: 3- 1 A- Z®l% COMPLIANCE DATE: 3- 1 - °Lc�t I
Separation Distance Between the: 3 „
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 0014 O 11 Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility Of any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY Cd1OL4,d e C-171 yr itS l.C.c.
A-1 =35` (3-f= 14-`
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A_3_y.�a y." 3-3=5+o
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Town of Barnstable
Department of Regulatory Services
Public
" Health Division
Fo.�� 200 Main Street,Hyannis MA 02601 Date
Date Scheduled �( r
Time ( Fc•e Pd.
Soil Suitability Assessment for Sewage Disposal
Performed By:
Witnessed By: 01,
]LOCATION& GENERAL FORMATION
[NEW
tion Address �l� n
0 ZN^J' ✓( �'�r Owner's Name *9
q.� 9vS%0
C,"
s T�J� Address
sor's Map/Parcel: w • ��`'� 0 Z C C F
I I I - 0 6.--? Engineer's Name
CONSTRUCI7ON REPAIR
Telephone# S6 F—73 7_4-7 6
Land Use
Slopes('%) Surface Stones /Q/A`
Distances from: Open Water Body7�u
ft Possible Wet Area 7 2�ft Drinking Water Well
Drainage Way f ( �ft
/� ft property Line f
ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands fn proximity ty to holes)
® r
r r
Parent material(geologic)
Depth to Bedrock------------------
/-
Depth to Groundwater. Standing Water in Hole: /0 —
Weepingfrom Pit Face
Estimated Seasonal High Groundwater
Method Used: DETERIVIINATION FOR SEASONAL HIGH WATER TABLE
Depth Observed standing in obs.hole: in, Depth to soli mottle:Depth to weeping from side of obs.hole: iI Groundwater mottleAdjuss.
in.
Index Well# Reading Date: Index Well level_w, Ad,t'd Groundwater
, ft.
J Adj.droundwater level
PERCOLATION TEST ;Hate Thne
Observation
Hole#
Time at 9"
Depth of Perc
Time at 6" �
Stan:Pre-soak Time @ t '^ S CA
Time(9"-6")
End Pre-soak
Rate MinJlnch
Site Suitability Assessment. Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back----------
***If percolation test is to be conducted within 100, of wetland,you must first notify the
Barnstable Conservation Division at least one(1) week prior to beginning.
Q:ISEPTICU'ERCFORM.DOC
DEEP.OBSERVATION HOLE LOG
Depth from Soil Horizon Soil Texture Hole#
Surface(in.) Soil Color Soil Other
(USDA) (Munsel) Mottling (Structure.Stones;Boulders.
COsisteng6 t3r�vell
to
to -y Z dS S� �� ���y
Z-�o C I L to yri g/3
ZS`P(-/ •
DEEP OBSERVATION HOLE LOG `Depth from Soil Horizon Soil Texture Role# 2—
Surface(in.) Soil Color Soil Other
(USDA) (Munsell) Mottling (•Gtructure,Stones, Boulders.
Q ( v Q- Qtten 9F 'rave_n�_
S
` Cl <S IQ
DEEP OBSERVATION HOLE LOG Hole#
�P�from Soil Horizon Soil Texture
Surface(in.) Soil Color Soil O��
(USDA) (Munsell) Mottling (Structure,Stones,Boulders.
o I to
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil
Surface(in.) Other(USDA) (Munsell) Mottling (Structure.Stones;Boulders.
Consi t
Flood Insurance Rate Man:
Above 500 year flood boundary No Yes
Within 500 year boundary N Yes y
Within 100 year flood boundary No. \� Yes _
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area!proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?„ J
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required trainin expertise and experience described in310 CMR 15.017.
Signature -
Date
Q:\S.Evnc%PERCFORM.DOC
No. 20I 1 — 05 v Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZIpprication for Od!5poal *paem Construction permit
Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot Ng. Owner's Name,Address,and Tel.No.
r-
3o - rw S�o4 -Cn - w �rns�le U�Vau S luu
Assessor's Map/Parcel ///_ .,rk S,OLL La'-,
Installer's Name,Address,and Tel.No. jw 7 if 77 4/7 7 3/3
Designer's Name,Address and Tel.No. ,S
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 33U O u gpd Design flow provided �3S�S 2 gpd
Plan Date 3-11- /1 Number of sheets o`Z Revision Date
Title
Size of Septic Tank /S uo 1Y,c) Type of S.A.S.��) /j rc ,3(,►(,
Description of Soil S_Ad
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date 3— I �4- 2-0 1 1
Application Approved by Date 3' lq- 7-0
Application Disapproved b Date
for the following reasons
Permit No. 20 I I - 656 Date Issued 3- l g-Zo L
No. 20 11 D Fee (V�'�J
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,. MASSACHUSETTS Yes
application for Migool *pgtem Cowaructton Permit
Application for a Permit to Construct( ) Repair(�j)' Upgrade(`) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.
30 -� r. s, (�-,L w. 9 rnsFahla
1�- �<l UQ�'vuS1uU 1
Assessor's Map/Parcel /0 _
Installer's Name,Address,and Tel.No. S4)g V 77 f k 77 Designer's Name,Address and Tel.No. z/7 7 $`3 3
Type of Building:
Dwelling No.of Bedrooms .3 Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building 12 z ) No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min. 'required) 330 . o gpd Design flow provided 3 S�f r Z gpd _
Plan Date 3- 1/— 11 Number of sheets o7 Revision Date
Title
Size of Septic Tank /S-u U H,U Type of S.A.S/ LZ o) cc- 3(-1(.,
Description of Soil r�
P S��d � �y0 SGt p(6n
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The under-signed agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a'Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date IN" 2-01 1
Application Disapproved b Date
for the following reasons
Permit No. 20 I) — VJ (0 Date Issued ,3 20 It
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that,the On-site Sewage Disposal System,Constructed ( ) Repaired (� Upgraded ( )
Abandoned( )by__ el/P_e u t(% & 4,non I!f
at '36 4 rnr Z/u has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.2 011— 0 S6 / dated Tbylzo1I
Installer Lneat�c i� �� /C.l),f Je I Designer flo 01 kV 0,f .t
#bedrooms 3 Approved design flok 'S 2. gpd
The issuance of this permit shall not be construed as a guarantee that the system wi 1 fu c�,n as desi ed.
Date 3 Inspector h
Y No. .7 Feed
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
Migo,5al *pf�tem Construction Permit
Permission is hereby granted to Construct ( ) Repair (� Upgrade ( ) Abandon ( )
System located at 3is�
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this perrnit.
Date y 7011 Approved by e----'
1
03/18/12011 15:34 5084775313 ENGINEERING WORKS PAGE 01
03/18/Zoli 15:1& FAA �ULS4L6J1l.O nr ��••+�
Town of Barnstable
Replatory Services
Thomas F.Geller,Director
Public Health Dion
.� Thomas McKean,Director
Zoo Maid Mtraet, I yMn sis,MA 03601
Fsx: 308-7W6304
offiw. SOS-362A6"
Date: - i f r ZvG f 'gowar Pe nmiw 'Zott - 0576 Assespor's MOPTarcel
Card.221ft Form
�
lam i nt4 r+✓` Wo�(l li �r`C Irdbl�el: ��Z w' t cJW �►'� -i''�'/
Deelgaar•
IZ Wo.s r Crt,st �Q1� � Addna:
Aaa�.•
MA
-�,rt'1 -2o1 .ala. was issued a,pemtlt to install a
. at".)
septic system at "3 o i r~e�:�4h- k's. w. �3 based cm a design dram by
�a�ress)
dated
( fie.)
,.I certify that the. septic system mfermoed-above wo installed substanti=on
ordhW to
the deal which may include minor.appmved chenge�s such as lateral of ttte
dlstribu on box and/or septic tank. Stripout (if required) was inspected and the soils
were found Satisfactory.
I certify dL&t the septic system r+efcrenccd above was installed vrith mapr changes (i.c.
men than 10' lat+eral r+aMcsstion of the SA5 or aay vertical relas3tion of any oomponent
of the septic system)but in accordarwc wittl State dt Locaf Regulations. P)an revision or
certified as-built by desigw. to follow. Stripout(if required) octed and the soils
were found satisfactory. �tw OF ,
1 PETER.7.
McMti
er 9 i CIV►t, w
,�I�o,astc o e
8t'E .
stgne�'s$IgnaWtwe' (A MIURN AM
AM
Nlam V
THANK M
c:1o,Him�rm.�dauprroat�w�on Aum.da .
M Page: 1
CERTIFICATE OF . ANALYSIS
�-` Barnstable County Health Laboratory
Report Prepared For: Report Dated: 03%10/2000
Vatousiou,Peter D. Order Number: G0005118
Peter D.Vatousiou
17 Sea Street Extension.
Hyannis, MA 02601
Laboratory ID#: 0005118-01 Description: WATER-Drinidng
Sample#: 05118-01 Sampline Location: 30 Ironside Drive W.Barnstable MA Collected: 02/24/2000
Collected by: Vatousiou Received: 02/24/2000
Routine+Ammonia
ITEM RESULT UNITS MDL MCL Method# Tested
LAB: IC Lab
Ammonia <0.1 mg/L 0.1 EPA 350.1 02/25/2000
Nitrates 0.3 mg/L 0.1 10 EPA 300.0 02/24/2000
LAB:Metals
Copper 0.2 mgrL 0.1 1.3 SM 3111B 03/02/2000
Iron 0.1 mg/L 0.1 0.3 SM 3111B 03/02/2000
Sodium 8 mg/L 1.0 20 SM 3111B 03/02/2000
LAB:Microbiology
Total Coliform Absent P/A 0 Absent P/A 02/24/2000
LAB: Physical Chemistry
Conductance 110 umohs/cm 1 EPA 120.1 02/24/2000
pH 6.1 pH-units 0 EPA 150.1 02/24/2000
Note: Water sample meets the recommended limits for drinking water of all above tested parameters.
.,
Superior Court House, PO. Bog 427, Barnstable, MA 02630 Ph: 508-375-6605
' ? Page: 2
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
Report Dated: 03/10/2000
Report Prepared For:
Vatousiou,Peter D. Order Number: G0005118
Peter D.Vatousiou
17 Sea Street Extension
Hyannis, MA 02601
Laboratory ID#: 0005118-02 Description: WATER-Drinldng
sample#: 30 Ironside sampling Location: 30 Ironside Drive W.Barnstable MA Collected: 02/24/2000
Collected by: Vatousiou Received: 02/24/2000
EPA 502.2- Volatile Organics by PdD/ECLD
ITEM RESULT UNITS MDL MCL Method# Tested
LAB: GC LAB '
1,1,1,2-Tetrachloroethane BRL ug/L 0.5 EPA 502.2 02/25/2000
1,1,1-Trichloroethane BRL ug/L 0.5 200 EPA 502.2 02/25/2000
1,1,2,2-Tetrachloroethane BRL ug/L 0.5 EPA 502.2 02/25/2000
1,1,2-Trichloroethane BRL ugfL 0.5 5.0 EPA 502.2 02/25/2000
1,1-Dichloroethane BRL ug/L 0.5 EPA 502.2 02/25/2000
1,1-Dichloroethene BRL ug/L 0.5 7.0 EPA 502.2 02/25/2000
1,1-Dichloropropene BRL ug/L 0.5 EPA 502.2 02/25/2000
1,2,3-Trichlorobenzene BRL ug/L 0.5 EPA 502.2 02/25/2000
1,2,3-Trichloropropane BRL ug/L 0.5 EPA 502.2 02/25/2000
1,2,4-Trichlorobenzene BRL ug/L 0.5 70 EPA 502.2 02/25/2000
1,2,4-Trimethylbenzene BRL ug/L 0.5 EPA 502.2 02/25/2000
1,2-Dibromo-3-chloropropan BRL ugtL 0.5 0 EPA 502.2 02/25/2000
1,2-Dibromoethane(EDB) BRL urn 0.5 EPA 502.2 02/25/2000
1,2-Dichlorobenzene BRL ug/L 0.5 600 EPA 502.2 02/25/2000
1,2-Dichloroethane BRL ug/L 0.5 5.0 EPA 502.2 02/25/2000
1,2-Dichloropropane BRL Us/L 0.5 EPA 502.2 02/25/2000
1,3,5-Trimethylbenzene BRL ug/L 0.5 EPA 502.2 02/25/2000
1,3-Dichlorobenzene BRL ug/L 0.5 EPA 502.2 02/25/2000
1,3-Dichloropropane BRL ug/L 0.5 EPA 502.2 02/25/2000
1,4-Dichlorobenzene BRL ug/L 0.5 5.0 EPA 502.2 02/25/2000
2,2-Dichloropropane BRL ug/L 0.5 EPA 502.2 02/25/2000
2-Chlorotoluene BRL ug/1. 0.5 EPA 502.2 02/25/2000
4-Chlorotoluene BRL ug/L 0.5 EPA 502.2 02/25/2000
Superior Court House, PO. Bog 427, Barnstable, MA 02630 Ph: 508-375-6605
Page: 3
i CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
Report Prepared For: Report Dated: 03/10/2000
Vatousiou,Peter D. Order Number: G0005118
Peter D.Vatousiou
17 Sea Street Extension
Hyannis, MA 02601
Laboratory ID#: 0005118-02 Description: WATER-Dr;nldng
Sample#: 30 Ironside Sampling Location: 30 Ironside Drive W.Barnstable MA Collected: 02/24/2000
Collected by: Vatousiou Received: 02/24/2000
Benzene BRL ug/L 0.5 5.0 EPA 502.2 02/25/2000
Bromobenzene BRL ug/L 0.5 EPA 502.2 02/25/2000
Bromochloromethane BRL ug/L 0.5 EPA 502.2 02/25/2000
Bromodichloromethane BRL ug/L 0.5 EPA 502.2 02/25/2000
Bromoform BRL ug/L 0.5 EPA 502.2 02/25/2000
Bromomethane BRL ug/L 0.5 EPA 502.2 02/25/2000
Carbon tetrachloride BRL ug/L 0.5 5.0 EPA 502.2 02/25/2000
Chlorobenzene BRL ug/L 0.5 100 EPA 502.2 02/25/2000
Chloroethane BRL ug/L 0.5 EPA 502.2 02/25/2000
Chloroform 1.1 ug/L 0.5 EPA 502.2 02/25/2000
Chloromethane BRL ug/L 0.5 EPA 502.2 02/25/2000
cis-1,2-Dichloroethene BRL ug/L 0.5 70 EPA 502.2 02/25/2000
cis-1,3-Dichloropropene BRL ug(L 0.5 EPA 502.2 02/25/2000
Dibromochloromethane BRL ug/L 0.5 EPA 502.2 02/25/2000
Dibromomethane BRL ug/L 0:5 EPA 502.2 02/25/2000
Dichlorodifluoromethane BRL ug/L 0.5 EPA 502.2 02/25/2000
Ethylbenzene BRL ug/L 0.5 700 EPA 502.2 02/25/2000
He%achlorobutadiene BRL ug/L 0.5 EPA 502.2 02/25/2000
Isopropylbenzene BRL ug/L 0.5 EPA 502.2 02/25/2000
Methyl-tert-butyl ether BRL ug/L 2.0 EPA 502.2 02/25/2000
Methylene chloride BRL ug/L 0.5 5.0 EPA 502.2 02/25/2000
n-Butylbenzene BRL ug/L 0.5 EPA 502.2 02/25/2000
n-Propylbenzene BRL ug/L 0.5 EPA 502.2 02/25/2000
Naphthalene BRL ug/L 0.5 EPA 502.2 02/25/2000
p-Isopropyltoluene BRL ug/L 0.5 EPA 502.2 02/25/2000
sec-Butylbenzene BRL ug/L 0.5 EPA 502.2 02/25/2000
Styrene BRL ug/L 0.5 100 EPA 502.2 02/25/2000
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph 568-375-6605
erH.;B CERTIFICATE OF ANALYSIS Page: a
Barnstable County Health Laboratory
Report Dated: 03/10/2000
Report Prepared For:
Vatousiou,Peter D. Order Number: G0005118
Peter D.Vatousiou
17 Sea Street Extension
Hyannis, MA 02601
Laboratory ID#: 0005118-02 Description: WATER-Drinlmtg
Sample#: 30 Ironside Sampline Location: 30 Ironside Drive W.Barnstable MA Collected: 02/24/2000
Collected by: Vatousiou Received: 02/24/2000
tert-Butylbenzene BRL ug/L 0.5. EPA 502.2 02/25/2000
Tetrachloroethene BRL ug/L 0.5 5.0 EPA 502.2 02/25/2000
Toluene. BRL uggL, 0.5 200 EPA 502.2 02/25/2000
Total xylenes BRL ug/L 0.5 10000 EPA 502.2 02/25/2000
trans-1,2-Dichloroethene BRL ug/L 0.5 100 EPA 502.2 02/25/2000
trans-1,3-Dichloropropene BRL ug/L 0.5 EPA 502.2 02/25/2000
Trichloroethene BRL ug/L 0.5 5.0 EPA 502.2 02/25/2000
Trichloroiluoromethane BRL ug/L 0.5 EPA 502.2 02/25/2000
Vinyl chloride BRL ug/L 0.5 2.0 EPA 502.2 02/25/2000
Note:
Approved By: `ice
(Lab Director)
3 /�'jLtaL7E;'
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
00 r 0
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BORTOLOTTI CONSTRUCTION, INC. s�`
45 INDUSTRY ROAD,MARSTONS MILLS,MA 02648 0 i e �
508-771-9399 508-428-8926 FAX: 508-428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:
_�,�kX_" A '-w-A
Date Of Inspection /1 9 Inspector's ame:
Owner's Name and Address: /
a2A Ocx_0o
CERTIFICATION STATEMENT:
I Certify that I have personally Inspected the Sewage Disposal System at this address and that the Informa-
tion reported below Is true,accurate and complete as of the time of Inspection. The Inspectloin.was perform-
ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis-
posal Systems.T e system:
Passes
Conditionally"ses
Needs Furt er valu ti By the Local Approving Authority
Failure
Inspector's Signature Date:
TheSystem Inspector shall submit a copy of this Inspection Report to the Approving Authority with Thirty
(30)Days of completing this Inspection. If the System is a Shared System or has a Design Flow of 10,000 gpd
or greater,the_Inspector and the System Owner shall submit the Report to the appropriate Regional Offie of
the Department of Environmental Protection. The Original should be sent to the System Owner and copies
sent to the Buyer,if,applicable and the Approving Authority.
INSPECTIU
A) SYST PASSES:,
I have not found any Information which i ndicates that the System violates any of the fail-
ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi-
cated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more System Components need to be Replaced or Repaired. The System,upon
completion of the Replacement or Repair,Passes Inspection.
Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not
determined",explain why not.
The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil-
tration,or Tank Failure is iimminent. The System will Pass Inspection if Existing Septic Tank
is Replacedvith a conforming Septic Tank as Approved by the Board Of Health.
Sewage Backup or Breakout or High Static Water Level observed in the Distribution Box is due to
broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box. The System
will pass Inspection if(With Approval of the Board Of Health):
-1 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
-- The system will pass inspection-if(with approval of-The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
C)FURTHER EVALUATION 1S REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by The Board of Health in order to determine if
the system is failing to protect the public health, safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECTTHE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is`within 50 Feet of a bordering vegetated wetland or.a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH,(AND PUBLIC WATER-
SUPPLIER,IF APPROPRIATE)DETERMINES,THAT.THE SYSTEMS FUNCTION-
ING IN A MANNER THAT,PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
a ENVIRONMENT:
The system has a septic tank and soil absorption system and is'within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from.a.priyate_water,supply well,unless a well water analysis for co ifoam
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health,
Should be contacted to determine what will be necessary to correct the failure. 4
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or.ponding of efluent to the surface of the+ground;or surface waters due to an
overloaded or clogged.SAS or cesspool. .
{ Static liquid level in the distribution box above outlet invert-due to an overloaded or clog-
ged SAS,or cesspool.- ,
Liquid depth in cesspool is less than 6"below invert'oravailable volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year MQT due to clogged or obstructed
pipe(s). Number of times pumped
2-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool.or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,.ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the following
conditions exist:
The system is within 400 Feet of a surface drinking water supply
The system is within 200 Feet of a tributary to a surface drinking water supply
The system is located in a nitrogen sensitive area Interim Wellhead Protection Area
(IWPA)or a mapped Zone I1 of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
.;,, .....:. CHECKLIST
Check if the following have been done:
_ZPumping information was requested of the owner,occupant,and Board of Health.
None of the system components have been pumped for atleast two weeks and the system has
,been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
✓ As-built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
_LThe system does not receive non-sanitary or industrial waste flow.
[_The site was inspected for signs of breakout.
_ All system components,excluding the.Soil Absorptions System,`have been located on site.
_The septic tank ritanholes"were uncovered,opened,and the inteiior of the septic tank was in
spected for condition of baffles or tees, material of construction,dimensions,depth of liquid,
depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3
?i 1 t
"A _ �,:.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART I)
CHECKLIST(continued)
✓The facility owner(and occupants, if different front owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RF4IDi g Ai V
Design Flow: 33C7 gallons Number of Bedrooms:_ Number of Current Residents:
Garbage Grinder: Laundry Connected'I'o System:(.�P�_ Seasonal Use:
Water Meter Readin ,if ailable:.
Last Date ofOccupancyl`Q; AY_�jts
_ CO MICR .-ATANDLI T IAI.�'��
Type of Establishment:
Design Flow: gallonstday Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System Pumped as part of inspection:_ If yei,v6luWe pumped: V '' `gallons'
Reason for pumping:
TYP_ $„OF:SYSTEM: ' '-
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
ROXMUTE AGE of ajI components,date installed(if known)and sddice,of information:.
Sewage odors detected when arriving at the site:
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK: /� cc-eial ofr 3
Depth below grade: Mater Constniction: ✓concrete metal FRP Other
(explain) —
Dimisions: .S'N ' Slud e De the
g p — 1_ Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle; 37
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid
level in relation to llet invert,structural integrity,evidence o eakage, etc.
GREASE TRAP: Aid
Depth Below Grade: Material of Constriction: concrete metal -FRP Other
(explain) -- -- —
. t
Dimensions: Scum Thickness:" _
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert, stnuctural integrity, evidence or leakage. etc.)
TIGHT OR HOLDING TANK:��
Depth Below Grade: Material of Construclion:_-._„concrete_meial`FRP_Other(explain)
Dimensions: Capacity: gallons Design Floe:_ gallons/day
Alarm Level:
Comments: (condition of inlet tee, condition of alar►n and Moat switches. etc.)
DISTRIBUTION BOX: V"
Depth of liquid level above outlet invert:
Comments: (note if I elkanddistrib1 4ution is e_qu"evidilice'of� solids carryover, evidence o leakag into
or out of x,etc.) Ah�tn�i�.� �
PUMP CHAMBER:/
Pum 'is in workin oider "P g ..
.Comments: (note condition of pump chamber,condition of pumps and a nrtenances etc.
i
� A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTIOYi SYSTEM(SAS): V
(Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
Type:
Leaching pits,number: Leaching chambers,_number: Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Comments:(note condition of soil,signs of hydraulic failure level of nding con ition o vegetati n,
c. '
4
17,
r
CESSPOOLS:
Number and configuration: Depth-top ofliquid io inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:
Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
N r 4 c
Al
,h Y
-6-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks o benchmarks.
Locate all wells within 100 Feet.
O
r
1
ju
DEPTH TO GROUNDWATER: ;
Depth to groundwater: L1,� Feet
Met4pd of Determination or Approximation:
POD
-7-
TOWN OF BARNSTABLE
LOCATION ZD7- 49 -4" SEWAGE # 3- 12(6
VILLAGE 6A)W 'j'"69LJy -ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. o 16i o eC®cc
4% SEPTIC TANK CAPACITY /Vvv
LEACHING FACILIT ':(type) , (size) Qe)
m
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATERie,
<.ZUILDER OR OWNER 1A ( j- 20-W
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No fl�
1
AM s
vse
�_ _ _ f KJ i
No..
}�+ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for Diipnsal Works Tonstrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address or Lot No.
Owner Address
a ...................................•------..........---•.....------......_._...................... ........------------.............__------••-----•-•-•-•...----•-..................__..._.._._.....
Installer Address
U Type of Building Size Lot__ }Z ..._Sq. feet
Dwelling—No. of Bedrooms.............I............................Expansion Attic ( ) Garbage Grinder ( )
'k Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ------------------------------•. .
W Design Flow................................ S---.gallons per person per day. Total daily flow........ _4?........................gallons.
WSeptic Tank—Liquid capacity_!_ K'r t.gallons Length.__ �e"_.. Width._ .Lr..... Dlameter-__�.__. Depth_.!�t.:'..
x Disposal Trench—No...........I........ Width------- Total Length.....i 6 ........ Total leaching area...ZA_,0------sq. ft.
Seepage Pit No.___.--•--_-:7-. Diameter._--A.%Q, ._. Depth below inlet----I.......... Total leaching area-LZ_.5_��_._sq. ft.
ZOther Distribution box (✓�r Dosing tank
. Percolation Test Results Performed by..... 'Z.............................. Date....J.. .................
,aa Test Pit No. I.....Z.----minutes per inch Depth of Test Pit_._.....!�Z...... Depth to ground water----_-----_•-_---_---.
f= ) Test Pit No. 2......?—.:...minutes per inch Depth of Test Pit........ :.._._ Depth to ground water-------� ........
a -•----••-- -•--------------••-••-•..................•••------------....•--••----...._....--•-....._..........-----••--------•.........---------------.......
xDescription of Soil--------- t=:3 ��= ` u •�-Z... " ---'+'tF/�C`` C,_�t / >
V -------------------•--------•-•-•-----------•--•--......•-•--••---.._._............------------•-----•------------------------•-•.....•-----•-------•--•.............------------•-----...--------------
W
--------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------......---...----
V Nature of Repairs or Alterations—Answer when applicable................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compli as een is d by th board f eal
Signed ..----j-. ---- .......-----
Application Approved By ... ..... ..... ......-----------------------------------.----
Dat
Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------------------------
- ----...- . ..........-------------------------------------- ----.- ....... Date
PermitNo. -------- ---------------------------- Issued ------- � U- �j ------------------
NO.. Fps... / .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE a
Appfiration for Dispasal Works Tomitrurtion jJamit
Application is hereby made`for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: r
.._......... _(''_7"..-�r. ?ORl_.....�f" !tJ�. yyr�._t i�'�1�' .......................�Z:_ .............................................
Location•Address or Lot No.
a\"
y3�j_ 2"aGGV$�I~-tA = A...............................................�.•�
Owner Address
W . ..._---••-- = !lam -it tik.v I
a -••---•---••----•........ .........•—=-••------.......---•�---------....---- � .' -----•-----..............
/ Installer j Address
Type of Building Size Lot..__=_____y _2 ....Sq. feet
Dwelling—No. of Bedrooms.__..._. ..........................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
04 Other fixtures ............................
W Design Flow................................ ___gallons per person per day. Total daily-flow___-4-'n._._........._.......___gallons.
WSeptic Tank—Liquid ca.pacity.Z94Z_,gallons Length-__ Diameter__-_''--__. Depth._:7�4 __
x Disposal Trench—No...........Z......... Width------
1__4. ...... Total Length.....z.4......... Total leaching area...7—&A------sq. ft.
Seepage Pit No----------- Diameter_:-- 11..... Depth below inlet_-f#.__._____. Total leaching area_-- ..sq. ft.
Z Other Distribution box (✓)� Dosing-tank ( ) ' _ w 1_,1
'-' Percolation Test Results Performed by___- Jq l !' :9isr fL+.��_':.�=j�LM-4. Date.... -��: .............
aTest Pit No. 1._�'_-_�-....minutes per inch Depth of Test Pit......%�_7 ..__ Depth to ground water.....�! ..........
(ZA •- Test Pit No. 2_- =_..minutes per inch Depth of Test Pit____2 r!_`.__. Depth to ground water_-__-�----:--_-___-
O Description of Soil-----
V -•---•-•...._..---•••-•--•---•-.....------•-•--...--•------•••-----•--•----•....---•••--•-----•••-••-••-•-••-•-•--••-•-•.....---••••................•..................................................
W -•................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
,. system in operation until a Certificate of Compli as een issued t board o health.
Signed ----' ,
c
Application Approved B .
LTate�.
Application Disapproved for the following reasons: -----------------------------------------------------------------------------................................................
-------------- -
---- ---- ---------------------
' /....L Y.. 9 .-...-1?ate------
Permit No. .......---- ------- Issued ..------ . ,
Dater
3
THE COMMONWEALTH OF MASSAC�IJSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ----------------- --------------------------- ---- --------------------------------------Installer
............................... ....................
at --.............5 0...... ` 2 .--...--,t��,�.. ►-------- ..;.........to..... . .......... --...--( -... ..........................
has been installed in accordance with the provisions of TITLE of The VSta �tvironmental Code as described in
the application for Disposal Works Construction Permit No. ..- - dated .................. }
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONSTRUED S A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE:.A: .= � �? / ; w .Tnsp ctor 4 <. .. .................._... ..--- -`----
{
r
hsj
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No... ...........:. ..... TO FEE.f_ 61 .__.__.... l
Disposal Works_T1anofr ion "pamit
Permission is/Kere by granted................. 1"'---•-•------•----.....-------............---------•-••--•-•--•--..........................----
to Construct r/ or Re air an Indi�1 ewa a Dis osal S st
( ) pp ( ) g P Y f�
at No...... ¢ ..�l.- "1 srs , ' a . � ��c,�r-�!. ?�, --�a t `---------------•-•---........---
Street Q
as shown on the application for Disposal Works Construction Permit Nq!k
Dated..........................................
................................
I ------•.-.--------•---______-______-__----._____--
DATE.--•----•----------------------•-----.......----.............•--•-•---•••-•-•- Board of Health
FORM 38908 HOBBS.&WARREN,INC.,PUBLISHERS
t
BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT LABORATORY REPORT
VOLATILE ORGANIC CHEMICAL ANALYTICAL RESULTS
Client: DALE CROWDER Collection Date: 06/08/93
Mailing Address:
Type of Supply: WELL
Well Depth (FT) : 80
Telephone:
Sample Location: IRONSIDE ROAD LAT. (DDMMSS) : Not Given
BARNSTABLE LONG. (DDMMSS) : Not Given
Collector: C STIEFEL Map/Parcel : LOT 42A
Affiliation: BCHD
Analytical Method: 502. 1=1 , 502. 2=2 , 503 . 1=3, 504=4 , 524 .1=5, 524 .2=6 ,
502 . 1/503=7
Contaminants Anal . Result MCL Detection
Detected Meth. ug/1 ug/l Limits (ug/1)
---------------------------------------------------------------------
Chloroform 2 1 . 2 0. 5
Only those compounds listed above were detected. Attached is a list of
compounds for which this sample was analyzed.
NOTE: Contaminant levels equal to or exceeding the Detection
Limits are reported .
MCL means Maximum Contaminant Level for EPA-regulated
compounds . (ug/l = micrograms per liter = Parts Per Billion)
The Environmental Protection Agency has set Maximum Contaminant Levels
(MCL) for the following compounds. This sample compares as follows:
COMPOUND MCL (in PPB)
Benzene 5.0 * level not exceeded *
Carbon Tetrachloride 5.0 * level not exceeded *
1 , 2-Dichloroethane 5.0 * level not exceeded *
ill-Dichloroethene 7 .0 * level not exceeded *
1 , 4-Dichlorobenzene 75 * level not exceeded *
1 , 1 , 1-Trichloroethane 200 * level not exceeded *
Trichloroethene 5.0 * level not exceeded *
Vinyl Chloride 2 . 0 * level not exceeded *
Comments or additional compounds found:
Thomas F. Bourne , Laboratory Director
Log Number: Bottle # E039 Date: June 11, 1993
BA
BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT
SUPERIOR COURT HOUSE
C t• BARNSTABLE, MASSACHUSETTS 02630
v �J
4A5e' DRINKING WATER LABORATORY ANALYSIS PHONE:362-2511
Ext. 337
Client: Dale Crowder Collector-, C. Stiefel
Mailing Address: Affiliation: _ BCHD
Time & Date of
Collection: 6/8/93 3:15 p.m.
Telephone: Type of Supply: well
Sample Location: Lot 42A Ironside Road Well Depth:
West Barnstable MA Date of Analysis: 6/9/93 11:45 a.m.
PARAMETER SAMPLE RESULT RECOMMENDED LIMITS
Total Coliform Bacteria/100 ml 0 0
H 6.7
Conductivity (micromhos/cm) 81 500.0
Iron m) <.1 0.3
Nitrate-Nitro en m <.1 10.0
Sodium m) 9 ' 20.0
Copper (ppm) <.1 1.3
I . XXXX Water sample meets the recommended limits for drinking of all above tested parameters.
II . Based only on results of the parameters' tested for this sample, the water is
suitable for drinking but may present the problems checked below:
A. Water sample has higher than average levels of Nitrate. Future monitoring is
recommended (2-3 times per year) to establish any upward trends.
B. The low pH of the water may shorten the useful life of the house's plumbing.
C. Water may present aesthetic problems (taste, odor, staining) due to
D. Water sample has high levels of sodium. Persons on low sodium diets should
consult their doctor.
III. Due to one or more of the reasons checked below, this water sample exceeds the
recommended maximum .contamination level for drinking water:
A. High Bacteria B. High Nitrates , -
REMARKS:
CC: BOH
CC: d�
Laboratory Director
85
1 +II
No. bedirom4 3 - - -
3/ i4poa.at
��.tin:ated Cow 330
c�pd
.C'ocu4 d-eua ti on i4 l00
abbue M rS X by U 5 G S map
we&
CO tv
t_✓8 A 4 1. _
.exec pad
I
/S M 75.0
y.�
Cat-De-,Saa p' .C'ot L12uleu
33,720 cS 924 �-
t
Q• • t 1 �. I 31�{ ..i i � a I � � ++
✓�I7giLl.Le '.�-0�-�-__.J-----�-__--"'-__'�-_'._' 1' i ! i i r ,_ ..t_.
so wide ,a n CIN 5 Jt c ifl ,
Ad,L Cape. f
cnetCcwsd� - f -q Id 9—Ra�b oad j 1 i
i I y ,a,, i►�9 026 /,-- 1 -,
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73.o Date 5-20-�93 I {-
hio .SeaGe
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1000 I_
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ISk t A Pt.Iq'j .Xa d .gin (hest 9� '� i
' 90't 31 r, ct6wde& I 1 {-
f Cot Lj2 A aa. ahown on a plan &.co4,&d
r i ,
Made 5-8=87 Ctwatrona dire on an adu.,ssed datum!
No wateh' encou�'
►��. -� ,-���; --��ta-o� lea . .;_ i
Pe-ca.. 2 ,turi pek1. i -1
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S, p / 9P2. I 4 I - � -
f ;!
1
p . . 71,o p: i/a
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d /16to I -_
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w wit A� FCC •c,..° ,. : � -{- t--.
h. with ; s�
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q,,=e.0
,
No.- �--- _�__==G� Fee--' - -�
BOARD OF HEALTH
TOWN OF BARNSTABLE
TippIication-*rVell Couotructiouperutit
Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( n individual Well at:
--5--A, 1e-------------------------------------------
Location — Address Assessors Map and Parcel
---------------- ---------6 .L-26--6-2-------fi
Owner Address
- H ---
Installer — Driller ' Address
Type of Building
Dwelling--------------------------------------------------------
Other - Type of Building------------------------------------ No. of Persons--------------------------------------------------------
Type of Well e` �
--------------- Capacity------------------------
--------------------------—------—-----------------
Purpose of Well--------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ___
D ------
____ �'�__`?�__�-�%�.'�,�� :- _
date
Application Approved BY---"" � L '
date
Application Disapproved for the following reasons:------______ _______^____-----_-----------------------—___----------
------------------------------- ---------------------------------------------------------------------------------
date
Permit No. ------I'll---— _ �r------------------------ Issued----------------------------------�---� ----------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
bY-------- --------- �'Ft- �_$-------------------------------------------------------------------------
Installer
at-------f - /�---------- - v-'1' -` `r ------ ---------------41—U--=------1�- 1411 IA.
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit :v z�'Dated----6
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-----------------—----------- ---------------------- Inspector------------------------------------------------------------------------------------
' 1
BOARD,OF HEALTH
TOWN OF BARNSTABLE
Applitation forlVeir Con5truct ion Permit
Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( t,)an'ind ivi dual Well at:
______ 11 r' - ----------- ---
-------------------------
� -Location - Andres - ,/� .1 Assessors Map and Parcel
-/ n �--------/D ,ram_ ;_ --------------------------- �-— / '- ----- 1~ �C_ 'a......
l _
j ! �J ____________ _____ __!_� - �T_- -__ V
Owner Q / Address `
�- yy�1✓ `� = ------------ - R' LP t t J7 --------� ? 'n
r-C� t`°L j, K�
Istaller - Driller Address
Type of Building
Dwelling-----------------------------------------------------------------
Other - Type of Building ----- No. of Persons------------------------------------------------------
Typeof Well—-— —"- `' `� E %--------------- Capacity--------—------------------------------------------------------—------------
Purposeof Well---------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed - ;"� f�r -- ------- -
date
Application Approved By--�-= G ¢ 6%4 ' - ---- .....
--- cra t '
Application Disapproved for the following reasons: - - - -------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
!^- date
"- t-Permit No. -----///-- ��'" � ��------------------- Issued-----------------"' � ------------------
date
0
BOARD OF HEALTH'
TOWN OF BARNSTABLE
Certifkate (Of CompWuce
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
-----------------------------------------------------------------------------------
by------y: ! `�/ fTv'�i' i =. v e f7InstalG�
at------- ' -r L'l_----------� --r t. -cr-= f ------- -- - - ,✓l
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit
'l� � Dated--- --- -= 3
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------------- Inspector-----------------------------------------------------------------------------------
,
BOARD OF HEALTH
TOWN OF BARNSTABLE
V ell ConStruct ion Permit
No.-�'y Fee�----`—
Permission is hereby granted------- --------------------------------------------------------------------------
to Construct ( /), Alter ( ), or Repair ( ) an Individual Well at:
.�s� � ��` � Y�r" ,✓ �GSA � b'treet C �� ' � ✓" /-7`---`,�... --- -� K...-..
as shown on the application for a Well Construction Permit ---�
1.1.1.,.- 100 ��•- � 4--------------------------- Dated---------�' � � r' _.�"-�� -�"' - - -----------
O.------------ ��------------ .cam.:,----
Board of Health
DATE-----' '� '`° -------------------------
No. bed/wom,, 3 6 -i `
b4APOdat no
��sturu�.ted Low 336 qpd
eacfu iu� 204
i _tr
/Zeae I 20�! 2� �toB -
aci ty 30 Vd
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LEGEND N
(T) r - /1"
-- 98--EXISTING CONTOUR - /��
X 100.98 EXISTING SPOT GRADE 3 �Q
0
♦ EXISTING WELL a �= William's Path
G EXISTING GAS SERVICE _ �Q
U UNDERGROUND WIRES /
o/q Ra J
TEST PIT Count
BENCHMARK Street
WETLAND SYMBOL
/LOW s?
0
1.00
/ Ironside Ln a
2 LOCUS MAP
NOT TO SCALE
6�78
m _
BENCHMARK
x 67.46 `-- --- Outside Cor. Conc. Apron
' -- 6s.66 - EL.=74.13 (Assumed)
VENT�0
64.2
72.50 '-----�z�------4-- -------------���' TP-1
x
.x a3.13 73.28
i �` x 9• �`�\ 1 O l`
EXISTING SEPTIC TANK-
173. _2& 73.as
TO BE PUMPED, FILLED WITH
SAND AND ABANDONED
r '
DECK �•� '
,=Y a s GARAGE
x 73.9' (SLAB)
EXISTING SEPTIC TANK Z Ott; EXIS77NG tt
(TO REMAIN) ,N00 HOUSE(#30)
`" ' r T.O.F.=75.00f `� t
74.2
TOP OF TANK=72.07 t
INV.(OUI)=70.74f CP STON_E::'.;':
IJ CO. 74.57 4 38
t/EWA Y`, 't
A. J r 4.
74.33+:3 V, S� GS 69.
O O. 74.19 / +701,53
RELOCATE PARKING TO ,
PREVENT TRAFFIC OVER +74.90 x 73.74 ! 't
SEPTIC TANK LDR ��
74.83
73.90
101
3 rr CP
'•F.73.15 i �
N �• •t 71.66
a 1
t t\ M Cp
75.53 75.41
B R CIV
75.78
t` r OF 69.34
t t
BL R 6. `�f6.21 SLOT 42A �`,� i'�g
76.54 ', �3,720±S.F. 't` I698
APK 111 -f,7
WELL i WELL , \
76.40 1 76.09 t ®/
t `t WF-4
70.64
703
\ S
75.07 edge x 75.
74.96 0/`
75
IRONSIDE 75g675.
LANE -1
OF Mgssyl-
o PETER T.
E PROPOSED SEPTIC SYSTEM UPGRADE PLAN
g McEPJTEE
CIVIL a 35109 30 IRONSIDE LANE, WEST BARNSTABLE, MA
^RIISTE- Prepared for: Capewide Enterprises LLC, P.O. Box 763, C3nterville, MA 02662
FS E OWNER OF RECORD Engineering by: SCALE DRAWN JOB. NO.
1 VATOUSIOU, PETER D Engineering Works, Inc. 1"=20' P.T.M. 123-11
�` ►� 1 t I 30 IRONSIDE DRIVE 12 West Crossfield Rood, Forestdale, MA 02644 DATE CHECKED SHEET NO.
W. BARNSTABLE, MA 02668 (508) 477-5313 3/11/11 P.T.M. 1 of 2
w
L(. NOTE: TO PREVENT BREAKOUT, THE PROPOSED
FINISH GRADE SHALL NOT BE < EL.65.8
FOR A DISTANCE OF 15' AROUND THE
PERIMETER OF THE S.A.S.
SEPTIC TANK PROPOSED D-BO PROPOSED S.A.S.
X INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT INSTALL INSPECTION PORT OVER END UNIT
T.O.F. 'OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE VENT-CONVENTIONAL
OR CHARCOAL
EXISTING F.G. 71.83(MAX.)
F.G. EL.=74.4t � F.G. EL: 72.0t
MAINTAIN 2% GRADE (MIN.) OVER S.A.S.
L = 49' L = 13'(MAX) INSPECTION
S=1% (MIN.) @ S=1% (MIN.) TOP LOAD ONITS PORT
4"SCH40 PVC 4"SCH40 PVC (1 MINIMUM)
LLI iD"I 6
t4" 19" TO
EXISTING 48" LIQUID INVERT
LEVEL ADD
GAS BAFFLE PROPOSED INV.=68.30
INV.=70.74t D-BOX 4 ROWS OF 5 UNITS AT 5.0'/UNIT = 25.0'
EXISTING INV.=66.58
EXISTING SEPTIC TANK SOIL ABSORPTION SYSTEM (PROFILE)
ESTABLISH VEGETATIVE COVER
BACKFILL WITH CLEAN NATIVE OR
PERC SAND TO TOP OF CHAMBERS
NOTES: INV. ELEV.=66:58
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE BREAKOUT=TOP
INVERTS„ PRIOR TO INSTALLATION. TOP ELEV.=66.33
2) D-BOX SHALL BE SET LEVEL AND TRUE TO
GRADE ON A. MECHANICALLY COMPACTED SIX BOTTOM ELEV.=65.00-
INCH CP.USH-D STONE BASE, AS SPECIFIED 5' MIN. ABOVE BOTTOM OF 2.83'
IN 310 CMR 15.221(2).
3) INSTALL INLET & OUTLET TEES AS REQUIRED. T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH=11.3'
4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE EXISTING SUITABLE
AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. NO G.W., EL=60.0 - MATERIAL
SYSTEM
4 ROWS OF 5-ADS Arc 36HC UNITS WITH NO
SEPTIC SYSTEM PROFILE SEPARATION BETWEEN EACH ROW & NO STONE
N.T.S. TYPICAL SECTION
SOIL LOG
DATE: MARCH 9, 2011 (REF# P-13,214)
SOIL EVALUATOR: PETER McENTEE (SE#1542)
WITNESS: DAVID STANTON-HEALTH AGENT
GENERAL NOTES: Elev. TP- 1 Depth Elev. TP-2 Depth
72.0 A 0" 73.5 A 0"
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL SANDY LOAM SANDY LOAM
BOARD OF HEALTH AND THE DESIGN ENGINEER.
2. ALL WORK .AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 71 2 10YR 4/2 10" 72 7 10YR 4/2 10„
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE B B
LOCAL RULES AND REGULATIONS EXCEPT AS REQUESTED BELOW: SANDY LOAM SANDY LOAM
-310 CMR 15.405(i)(b): 1OYR 5/4 10YR 5/4
1) A 3' variance to the 3' maximum cover requirement, for 6' of 68.5 42" 70.0 42'
max. cover. S.A.S. shall be H-20 and vented. C1 C1
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR SANDY LOAM SANDY LOAM
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. 10YR 5/3 1OYR 5/3
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 67.0 60" 65.5 96'
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN C2 C2
ENGINEER BEFORE CONSTRUCTION CONTINUES.
5. ALL ELEVATIONS BASED ON ASSUMED DATUM.
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF MED. SAND MED. SAND
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 2.5Y 6/4 2.5Y 6/4
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
7. WATER SUPPLY PROVIDED BY PRIVATE WELL.
8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S.
9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS 60.0 144" 61.0 150"
AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE
DIRECTED BY THE APPROVING AUTHORITIES. PERC RATE <2 MIN/IN. IN SAND (RECORD)
10, IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY NO GROUNDWATER OBSERVED
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
CONSTRUCTION.
63.25"
11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND
REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). r16"
12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE
INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL, 34.5"
13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND
IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY.
TOP VIEW
DESIGN CRITERIA 60"
END CAP END CAP
NUMBER OF BEDROOMS: 3 BEDROOMS FRONT VIEW SIDE VIEW
SOIL TEXTURAL CLASS: CLASS I END CAP
DESIGN PERCOLATION RATE: <2 MIN/IN REAR/TOP VIEW
fig DAILY FLOW: 330 G.P.D. To CHANCE WITHOUTNOTE: UNIT RNO ICE. PRODUCTATION AND ADETALSMAYECT SIDE VIEW
DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE.
DESIGN FLOW: 330 G.P.D.
4640 TRUEMAN BLVD
GARBAGE GRINDER: NO HILLIARD. OHIO 43026 Arc 36HC DETAIL
LEACHING AREA REQUIRED: (330) = 445.9 S.F. ADVANCED DRNINAGE SYSTEMS,INC.am.
UNITS MUST BE STAMPED H-20 kk
'74 PROPOSED SEPTIC SYSTEM UPGRADE PLAN
EXISTING SEPTIC TANK: 1000 GALLON CAPACITY
PROPOSED D-BOX:: 1 INLET, 4 OUTLET (MINIMUM) 30 IRONSIDE LANE, WEST BARNSTABLE, MA
USE 4 ROWS OF 5-ADS Arc 36 UNITS WITH NO Prepared for: Capewide Enterprises LLC, P.O. Box 763, C3nterville, MA 02662
SEPARATION BETWEEN EACH ROW & NO STONE Engineering by: SCALE DRAWN JOB. NO.
BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.80 SF/LF OF UNIT) Erlio g Works, Inc. n.t,s. P.T.M. 123-11
(Arc36HC Units) 20 UNITS x 5.0 LF x 4.80 SF/LF = 480.0 SF 12 West Cross I Id Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
DESIGN FLOW PROVIDED: 0.74(480.0 S.F.) = 355.2 G.P.D. (508) 477-5313 3/11/11 P.T.M. 2 Of 2